Previous work on somatic delusions. Suggestion that allopsychic delusions
are as a rule in some sense autopsychic. A genetic hint from general
paresis (frontal site of lesions in cases with autopsychic trend.) Mental
symptomatology of general paresis. Work on fifth-decade psychoses.
Statistical summary. Group with pleasant (or not unpleasant) delusions.
Three cases of senile dementia, delusions of grandeur, and frontal lobe
changes. Three cases with religious delusions. Remainder of
pleasant-delusion group. Group with unpleasant delusions. Nephrogenic
group.
THE suggestions here put forward concerning personal (autopsychic) delusions
are based on material of the same sort as that previously analyzed for a
study of somatic and of environmental (allopsychic) delusions. Our
conclusions are also influenced by two analyses of the types of delusion
found in general paresis. Moreover, at a period subsequent to the analysis
presented here, some work on fifth-decade insanities had been completed, and
the delusional features constantly found in the functional cases of insanity
developing at the climacteric, entered to modify our general point of view.
The situation may be summed up as follows:
The accessibility to analysis of the clinical and anatomical data at the
Danvers State Hospital was such as to prompt the use of its card catalogues
for statistical work upon delusions. The more so, because in a period of
enthusiasm over the Wernickean trilogy (autopsyche, allopsyche,
somatopsyche) of conscious phenomena, the Danvers catalogue had attempted to
divide the delusions recorded into the three Wernickean groups. Putting
these clinical data side by side with the anatomical data, we were speedily
able to single out those cases with normal or normal-looking brains and thus
to secure a group approximately composed of functional cases of insanity.
It shortly developed, as to the CONTENT of delusions, that somatic delusions
were exceedingly prone to parallel the conditions found in the trunk-viscera
and other non-nervous tissues of the subjects at autopsy.) A subsequent
study has confirmed this conclusion for the distressing hypochondriacal
delusions found in climacteric insanities, which delusions, however
distressing, are often far less so than the true conditions found at
autopsy. And it may be generally stated that the clinician can get very
valuable points concerning the somatic interiors of his patients by
reasoning back from the contents of their somatic delusions.
But how far can we, as psychiatrists, reason back from the contents of
environmental delusions, e. g. those of persecution, to the actual
conditions of a given patient's environment? In a few cases it seemed that
something like a close correlation did exist between such allopsychic
delusions and the conditions which had surrounded the patient--the delusory
fears of insane merchants ran on commercial ruin, and certain women dealt in
their delusions largely with domestic debacles. But on the whole, we could
NOT say that, as the somatic delusions seemed to grow out of and somewhat
fairly represent the conditions of the some, so the environmental delusions
would appear to grow out of or fairly represent the environment.
Thus, however brilliant an idea was Wernicke's in constructing the
allopsyche (or, as it were, social and environmental side of the mind) for
the purpose of classification, our own analysis promised to show that for
genetic purposes the allopsyche was much less valuable. These delusions
having a social content pointed far more often inwards at the personality of
the patient than outwards at the conditions of the world. And case after
case, having apparently an almost pure display of environmental delusions,
turned out to possess most obvious defects of intellect or of temperament
which would forbid their owners to react properly to the most favourable of
environments. Hence, we believe, it may be generally stated that the
clinician is far less likely to get valuable points as to the social
exteriors of his patients from the contents of their social delusions than
he proved to be able to get when reasoning from somatic delusions to somatic
interiors. Put briefly, the deluded patient is more apt to divine correctly
the diseases of his body than his devilments by society.
Our statistical analysis, therefore, set us drifting toward disorder of
personality as the source of many delusions apparently derived ab extra and
tended to swell the group of autopsychic cases at the expense of the
allopsychic group,
In the statistical analysis of a group of cases corresponding roughly with
the so-called functional group of diseases, we find false beliefs about the
some on a somewhat different plane from those about the patient's self and
his worldly fortunes. We can even discern through the ruins of the paretic's
reaction that his false beliefs concerning the body are often not so false
after all, and that his damaged brain of itself is not so apt to return
false ideas about his somatic interior as about his worldly importance and
plight. There then seems to be more reality about somatic than about
personal delusions: the contents of somatic delusions are rather more apt to
correspond with demonstrable realities than the contents of personal
delusions. Accordingly our analysis of delusional contents includes a hint
also as to genesis. Taken naively, the facts suggest a somatic genesis for
somatic delusions exactly in proportion as these delusions are not so much
false beliefs as partially true ones.
What genetic hint have we for the delusions concerning personality? One
genetic hint was obtained from a correlation of delusions with lesions in
general paresis,[2] in which disease perhaps the most profound and
disastrous of all alterations of personality are found. Amidst the other
alterations of personality found in paresis, autopsychic delusions are
characteristic: indeed allopsychic delusions are conspicuously few in our
series. And, as above, the somatic delusions, fewer in number, can be
fairly easily correlated with somatic lesions, or else with lesions of the
receptor apparatus (thalamus) of the brain.
Now it was precisely the cases with autopsychic delusions, as well as with
profound disorder of personality in general, that showed the brunt of the
destructive paretic process in the frontal region. The other
not-so-autopsychic cases did not show this frontal brunt, but were less
markedly diseased at death and had a more diffuse process.
Our genetic hint from paresis, therefore, inclines us to the conception that
this disorder of the believing process is more frontal than parietal, more
of the anterior association area than of the posterior association area of
the brain. And if we can trust our intuitions so far, the perverted
believing process is thus more a motor than a sensory process, more a
disorder of expression than a disorder of impression, more a perversion of
the WILL TO BELIEVE than a matter of the rationality of a particular credo.
Again we may appear to burst through from an undergrowth of statistics into
the clear field of truism. False beliefs are more practical than
theoretical, more a matter of practical conduct than of passive experience,
more a change of reagent than a reaction to change. The man on the street or
even many a leading neurologist would perhaps accept this formula as his
own.
Certainly in general the least satisfactory of these chapters on the nature
of delusions was the chapter on environmental effects,[3] and this perhaps
because the results seemed so nearly negative.
A further contribution to delusions of environmental nature was somewhat
unexpectedly derived from a piece of work on the general mental
symptomatology of general paresis.[4] Dichotomizing the paretics (all
autopsied cases) into a group with substantial, i. e., encephalitic,
atrophic or sclerotic lesions of the cortex and a group without such gross
lesions or else with merely a leptomeningitis, I found the latter (or
anatomically mild) group to be characterized by a set of symptoms which were
all "contra-environmental," whereas the former (or anatomically severe) did
not thus run counter to the environment. The conclusions of that paper, so
far as they concern us now, are as follows:--
The "mild" cases showed a group of symptoms which might be termed
contra-environmental, viz. allopsychic delusions, sicchasia (refusal of
food), resistiveness, violence, destructiveness.
The "severe" cases showed a group of symptoms of a quite different order,
affecting personality either to a ruin of its mechanisms in confusion and
incoherence, or to mental quietus involved in euphoria, exaltation, or
expansiveness.
The most positive results of this orienting study appear to be the
unlikelihood of euphoria and allied symptoms in the "mild" or non-atrophic
cases and the unlikelihood of certain symptoms, here termed
contra-environmental, in the severe or atrophic cases. Perhaps these
statistical facts may lay a foundation for a study of the pathogenesis of
these symptoms. Meantime the pathogenesis of such symptoms as amnesia and
dementia cannot be said to be nearer a structural resolution, as these
symptoms appear to be approximately as common in the "mild" as in the
"severe" groups.
But in both papers dealing with paresis [2,4] we rest under the suspicion
that the delusions are possibly of cerebral manufacture. Of course, a lesion
somewhere outside the brain is not unlikely to be projected through the
diseased brain, and SOMATIC delusions in the paretic are rather likely to
represent something in the viscera.
It was desirable to get back to normal-brain material, to learn how the
INTRINSICALLY NORMAL brain[5] could perhaps produce delusions from a
particular environment. Could a particularly "bad" environment actually
PRODUCE delusions?
By chance, at about this stage in our studies of delusions, some work on
fifth-decade insanities[6] was completed. This work seemed to show that the
most characteristic (non-coarsely-organic) cases of involutional origin were
much given to delusions (each of 24 cases studied), somewhat more so than to
the hypochondria and melancholia which we commonly ascribe to the involution
period. But this result is equivocal as to the environmental (i. e.
allopsychogenic) power to produce delusions, since one could not rid oneself
of the suspicion that the delusions were due to the degenerating brain.
To return to our former results with the normal-looking brain:
Case after case of the quasi-environmental group proved to be more
essentially personal than environmental, until at last it almost seemed that
the environment could seldom be blamed for any important share in the
process of false belief. In short, we seemed to show that environment is
seldom responsible for the delusions of the insane.
Be that as it may, we secured several lines of attack on the delusions of
personality by our study of quasi-environmental delusions. First, we were
irresistibly led to a consideration of the emotional (pleasant or
unpleasant) character of the delusions. We heaped up a large number of
unpleasant delusions in that (quasi-environmental, but actually) personal
group. It is interesting to inquire, accordingly, whether our more obviously
autopsychic cases will also be possessed of an unpleasant tone. Secondly, we
came upon the curious fact that cardiac and various subdiaphragmatic
diseases were correlated with unpleasant emotion as expressed in the
delusions. It was therefore important to inquire whether similar conditions
prevailed in the new group. Thirdly, we found ourselves inquiring whether
our patients were victims of what might be termed a spreading inwards of the
delusions (egocentripetal) or a spreading outwards thereof (egocentrifugal
delusions). But this difference in trend, clear as it often is from the
patient's point of view, remains to be defined from the outsider's point of
view.
Again, it remains to determine, if possible, how far delusions are dominated
respectively by the intellect or the emotions, or even by the volitions.
As before, I begin with a brief statistical analysis.